Department of Alcoholic Beverage Control State of California

Gavin Newsom, Governor

APPLICATION QUESTIONNAIRE
Please read instructions, which includes Privacy Notice, before completing form.
1. APPLICANT'S NAME(S) (If an individual, first name, middle name, last name. Name of entity if corporation, limited partnership or limited liability company.)

P-12 LICENSEE

Yes No
(If yes, complete form ABC-811)
2. LICENSE TYPE(S) (Check appropriate items) 3. TRANSACTION TYPE (Check appropriate item)
20 Off-Sale Beer & Wine Original (New)
21 Off-Sale General Person-to-Person Transfer (check appropriate section):
40 On-Sale Beer Section 24071 (Surviving spouse, corporations, fiduciaries, etc.)
41 On-Sale Beer & Wine Eating Place Section 24071.1 (Corporate Stock/Limited Partnership)
42 On-Sale Beer & Wine Public Premises Section 24071.2 (Limited Liability Company)
47 On-Sale General Eating Place Premises-to-Premises Transfer
48 On-Sale General Public Premises Exchange
Other Other
4. TEMPORARY PERMIT REQUESTED (Person-to-Person transfers only)
Yes No
5. PREMISES ADDRESS (Where license to be issued) (Street number and name, city, zip code) County

6. PREMISES TELEPHONE NUMBER 7. PREMISES ARE INSIDE CITY LIMITS 8. BUSINESS NAME (DBA) YOU WILL USE
Yes No
9. BUSINESS MAILING ADDRESS (Street number and name, city, state, zip code) 10. MAILING ADDRESS
Permanent Temporary
11. ABC LICENSE COST (Item #33a on reverse) 12. SUBTOTAL (Item #33f on reverse)

13. HAS THE APPLICANT(S) EVER BEEN 14. HAS THE APPLICANT(S) EVER VIOLATED ANY OF THE PROVISIONS OF THE ALCOHOLIC BEVERAGE CONTROL ACT OR REGULATIONS
CONVICTED OF A FELONY? OF THE DEPARTMENT PERTAINING TO THE ACT?
Yes No Yes No
15. IF YES TO ITEM 13 OR 14, PLEASE EXPLAIN

16. TRANSFEROR'S NAME (If an individual, last, first, middle. Name of entity if corporation, limited partnership or limited liability company.) 17. ABC LICENSE NUMBER

18. TRANSFEROR'S PREMISES ADDRESS (Where license is now issued) (Street number and name, city, zip code)

19. PREMISES UNDER CONSTRUCTION IF YES, LIST ESTIMATED COMPLETION DATE 20. FRANCHISE
Yes No Yes No
21. NAME OF PERSON WE MAY CONTACT (For the applicant) 22. TITLE OF CONTACT PERSON

23. CONTACT TELEPHONE NUMBER 24. CONTACT E-MAIL ADDRESS

25. PREMISES IS CURRENTLY LICENSED IF YES, TYPE OF LICENSE 26. CURRENT LICENSE IS OPERATING IF NO, DATE CLOSED
Yes No Yes No
FINANCIAL INFORMATION
27. ESCROW COMPANY'S NAME ESCROW COMPANY'S ADDRESS TELEPHONE NUMBER

28. BOOKKEEPER/ACCOUNTANT'S NAME BOOKKEEPER/ACCOUNTANT'S ADDRESS TELEPHONE NUMBER

29. LANDLORD'S NAME LANDLORD'S ADDRESS TELEPHONE NUMBER

30. MONTHLY RENT 31. LEASE EXPIRATION DATE 32. INDICATE WHETHER LEASE OR RENTAL AGREEMENT INCLUDES FURNITURE OR FIXTURES

All Some None

ABC-217 (rev. 01/19)
 COST
33. INVESTMENT INFORMATION

a. ABC License $

b. Furniture/fixtures $

c. Inventory $
d. Goodwill/non-compete
covenant $

e. Leasehold and/or Improvements $

f. SUBTOTAL (Usually should equal the recorded notice) $

g. Fees for other licenses, permits, and deposits (approximate). Include Federal, State,
County or City license fees or permits; lease and utility deposits $

h. Working capital (approximate) $

i. Realty or interest therein $

j. TOTAL INVESTMENT (Items f through i) (will equal total of amounts listed in item #33) $ 0.00
34. Source of Funds for Total Investment (item #33j) - identify amount(s), type(s) and explain source(s) and/or terms of Repayment

Amount Type Source and/or Terms of Repayment

$1,000 Gift John Doe, Brother
$15,000 Promissory Note to seller, payable @ $1,000 per month for 15 months
$10,000 Loan from ABC Bank, @ 8.5% over 5 yrs; monthly payment = $2,052

35. LIST ALL BANK ACCOUNTS FOR THIS BUSINESS OPERATION

BANK NAME BANK ADDRESS ACCOUNT NUMBER

a.

b.
c. NAMES OF ALL PERSONS AUTHORIZED TO SIGN ON BANK ACCOUNT(S) (Print)

I understand that falsification of the information on this form may constitute grounds for denial or revocation of the license(s).
For a period of 90 days from this date, I/we hereby authorize the Department of Alcoholic Beverage Control, or any of its officers,
to examine and secure copies of financial records consisting of signature cards, checking and savings accounts, notes and loan
documents, deposit and withdrawal records, and escrow documents of my/our financial institution(s) or any financial records
established in connection with this business. This authorization to examine records at any financial institution may be revoked at any
time. I/we also authorize the Department of Alcoholic Beverage Control, or any of its officers, to examine and secure copies of any
business records or documents established in connection with this business including, but not limited to those on file with my/our
bookkeeper. I/we also read all of the above and declare under penalty of perjury that each and every statement is true and correct.
36. APPLICANT SIGNATURE (Only one signature needed) PRINTED NAME DATE SIGNED

ATTEST (ABC Employee or Notary Public)

ABC-217 (rev. 01/19)